Full Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pre-Procedure Questionnaire
Are you under the influence of drugs or alcohol?
Yes
No
FEMALE ONLY: Are you currently pregnant or nursing?
Yes
No
Skin conditions (e.g. Rashes, eczema, infection, psoriasis, freckles, etc.)
If yes, please identify the condition.
Medical History (e.g. DIabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)
If yes, please identify the condition.
Acknowledgment and Waiver
*
I understand that this procedure is a permanent change to my skin and body.
*
I allow my tattoo to be photographed and be showcased in the artist's portfolio online and print and understand that revenue from media content of myself and my tattoo is property of the artist.
*
I acknowledge that Katharsis Tattoo does not offer refund.
*
I agree that the studio does not have a way of identifying if I am allergic to the elements or ingredients that will be used for my tattoo.
*
I understand that I need to take care of the tattoo by following the instructions given to me by Katharsis Tattoo.
*
I understand that I might get an infection if I don't follow the instructions given to me in regards of taking care of my tattoo.
*
I indemnify and hold harmless Katharsis Tattoo against any claims, expenses, damages, and liabilities.
*
I confirm that the information I provided in this document is accurate and true.
Signed Date
*
-
Month
-
Day
Year
Date
Client Signature
Submit
Should be Empty: